(+)Heather M.

Murphy-Lavoie, MD Assistant Residency Director and Assistant Professor, Louisiana

State University, Section of Emergency Medicine, New Orleans, Louisiana

Approach to the Unknown Rash

How do you approach the unknown rash? Knowing how to identify and classify a skin lesion is an
essential component in developing a systematic and organized approach to any lesion. The speaker will
present guidelines for the proper diagnosis of various dermatologic conditions using case presentations to
illustrate these concepts.
• Describe dermatologic conditions by the type of lesion and the distribution area.
• Develop a systematic approach to assessing and treating skin lesions.
• Identify dermatologic conditions requiring emergency interventions.
• Discuss appropriate differential diagnoses, treatments, and dispositions for patients with dermatologic
complaints.
MO-191 10/17/2011 10:00 AM - 10:50 AM Moscone Convention Center
(+)No significant financial relationships to disclose
Approach To The Unknown Rash
By Heather Murphy-Lavoie, MD
I. Introduction
a. There are more than 3000 dermatologic diagnoses b. Approximately 5% of
ED visits are for a dermatologic
complaint c. Objectives
i. Describe dermatologic conditions by the type of lesion
and the distribution area. ii. Develop a systematic approach to assessing
and treating
skin lesions. iii. Identify dermatologic conditions requiring emergency
interventions. iv. Discuss appropriate differential diagnoses, treatments,
and dispositions for patients with dermatologic complaints.
II. History
a. Age b. Duration c. Associated symptoms
i. Itching ii. Fever iii. Pain d. Travel/Location e. Sick Contacts f. Past Medical
History g. Medications – new h. Menstrual history i. Sexual history j.
Vaccinations
III. Physical Exam
a. Vital signs
i. Hypotension ii. Tachycardia iii. Fever iv. Mental Status Change
b. Distribution
i. Central ii. Peripheral iii. Flexural surfaces iv. Intertriginous v. Dermatomal
vi. Neurotic Excoriation vii. Extensor surfaces viii. Mucosal surface
involvement c. Appearance
i. Scaly/Moist ii. Color iii. Hyper/hypopigmented iv. Honey Crusted
v. Umbilicated vi. Blanching vii. Palpable d. Wood’s Lamp
i. Microsporum Tinea Capitus (green) ii. Erythrasma (coral red)
IV. Algorithms
a. Erythematous b. Maculopapular c. Petechiae/Purpura d. Vesiculo-bullous
Reproduced with Permission from : Murphy-Lavoie H, LeGros T. “Emergent Diagnosis of The
Unknown Rash, The Algorithmic Approach.” Emergency Medicine: A Peer Reviewed Journal, March
2010.
Differential Diagnosis:
Staph SSS = Staphylococcal Scaled Skin Syndrome - children, IV Penicillinase- resistant
penicillin, IV Fluids, local wound care Toxic Shock Synd= Toxic Shock Syndrome - look
for source (eg. a tampon) and remove, IV Penicillinase-resistant penicillin, IV fluids,
supportive care, hospital admission Kawasaki= Kawasaki’s Disease - children, mucous
membranes, lymph nodes, hands and feet, elevated platelet count, treat with immune
globulin, aspirin Scarlet Fever - children, sandpaper-like rash, strawberry tongue,
tonsillitis, treat with penicillin TEN = Toxic Epidermal Necrolysis - adults, drug reaction-
often sulfa, treatment remove offending source, wound care, IV fluids, admit to burn
center Anaphylaxis - treat with steroids, antihistamines, H2 blockers and possibly
epinephrine (0.3mg IM) for the most severe cases Scombroid - history of eating fish
recently, treat with antihistamines, usually self- limited Alcohol flushing - history of alcohol
ingestion, prior episodes, no itching, normal vitals, no fever, self-limited

ALGORITHM ERYTHEMATOUS RASH

Reproduced with Permission from : Murphy-Lavoie H, LeGros T. “Emergent Diagnosis of The
Unknown Rash, The Algorithmic Approach.” Emergency Medicine: A Peer Reviewed Journal, March
2010.
Differnetial Diagnosis:
Viral Exanthem - Measles, Rubella, Fifths, etc, self-limiting, supportive care Lyme Disease
- Tick bite, erythema migrans, arthralgias, headache, doxycycline

ALGORITHM MACULOPAPULAR RASH

Reproduced with Permission from : Murphy-Lavoie H, LeGros T. “Emergent Diagnosis of The
Unknown Rash, The Algorithmic Approach.” Emergency Medicine: A Peer Reviewed Journal, March
2010.
Pityriasis - scaly lesions, herald patch, Christmas tree pattern, treatment includes: UV
light, moisturizing lotion, oatmeal bathes, antihistamines Drug Reaction - remove the drug,
symptomatic treatment Stevens-Johnson Syndrome - mucosal involvement, remove
drug/treat illness, supportive therapy, hospital admission EM = Erythema Multiforme -
treat illness/stop drug, supportive care, topical steroids and outpatient follow-up for minor
cases Meningiococcemia - ill appearing, mental status change, lumbar puncture,
ceftriaxone, isolation, treat close contacts, hospital admission RMSF = Rocky Mountain
Spotted Fever - tick bite, endemic area, headache, arthralgias, doxycycline Scabies -
excoriated burrows, itches worse at night, permethrin

ALGORITHM VESICULO-BULLOUS RASH

Differential Diagnosis:
Varicella/Chicken Pox – excoriated lesions in multiple stages, starts centrally, isolate, rare
hospitalization, symptomatic treatment, antipyretics (not Aspirin) Small Pox – all lesions in
one stage, more peripheral distribution, isolate, notify office of public health and CDC
Disseminated GC= Gonococcemia - purple vesicles, sparce, peripheral, associated
urethritis/cervicitis/septic arthritis, ceftriaxone Purpura Fulminans/DIC = Disseminated
Intervascular Coagulation - treat the underlying cause, fresh frozen plasma, platelet
transfusions, ICU admission Necrotizing Fasciitis – surgical emergency, debridement, IV
anti-streptococcal broad spectrum antibiotic, hyperbaric oxygen therapy Hand, Foot and
Mouth Disease – children, vesicles on palms, soles and in mouth, self-limited, symptomatic
treatment Bullous Pemphigus -chronic autoimmune blistering, elderly, usually benign,
steroids Pemphigus Vulgaris – mucous membrane involvement, much higher mortality
than Bullous Pemphigus, steroids, admission Zoster – acyclovir, analgesia, steroids Contact
Dermatits - symptomatic treatment, long taper of steroids for severe cases Dyshidrotic
Eczema - topical steroids
Reproduced with Permission from : Murphy-Lavoie H, LeGros T. “Emergent Diagnosis of The
Unknown Rash, The Algorithmic Approach.” Emergency Medicine: A Peer Reviewed Journal, March
2010.
Differential Diagnosis:
Meningiococcemia - ill appearing, mental status change, lumbar puncture, ceftriaxone,
isolation, treat close contacts, admission Disseminated GC= Gonococcemia - purple
vesicles, sparse, peripheral, associated urethritis/cervicitis/septic arthritis, ceftriaxone
Endocarditis – new murmur, vegetations on valves, positive blood cultures RMSF = Rocky
Mountain Spotted Fever - tick bite, endemic area, headache, arthralgias, doxycycline HSP
= Henoch Schonlein Purpura – children, associated arthralgias, hematuria and GI
symptoms, supportive therapy TTP= Thrombotic Thrombocytopenic Purpura - low
platelet count, fever, neuro sx, hemolytic anemia, renal failure, ICU admission, treat
underlying cause, plasmapheresis, splenectomy, selective transfusion, NO platelets
Vasculitis – treat the underlying process if possible, may require steroids ITP – Idiopathic
Thrombocytopenic Purpura - transfuse platelets if bleeding or less than 5000/mm3 –
10000/mm3, emergent Hematology consultation

ALGORITHM PETECHIAL/PURPURIC RASH

Reproduced with Permission from : Murphy-Lavoie H, LeGros T. “Emergent Diagnosis of The
Unknown Rash, The Algorithmic Approach.” Emergency Medicine: A Peer Reviewed Journal, March
2010.
VI. Appendix
V. Summary
With the type of lesion, distribution, and whether or not the patient is ill, one
can narrow the diagnosis down to one or two diagnoses in many cases.
Reproduced with Permission from : Murphy-Lavoie H, LeGros T. “Emergent Diagnosis of The
Unknown Rash, The Algorithmic Approach.” Emergency Medicine: A Peer Reviewed Journal, March
2010.
a. More Definitions
i. Erosion- loss of epidermis only ii. Ulcer- extends below epidermis to involve dermis and
subcutaneous
tissue iii. Fissure- linear split in skin iv. Excoriation- linear superficial erosions or crusts due
to scratching
v. Wheal- soft smooth, raised papule, light pink (eg. Urticaria) vi. Burrow- linear “S” shaped
papule 3-5mm long vii. Purpura- > 1 cm does not blanch with pressure, red/purple macules
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